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Background Public health interventions are directed towards social systems and it is difficult to foresee all consequences. While targeted outcomes may be positively influenced, interventions may at worst be counterproductive. To include self-reported health in an evaluation is one way of addressing possible side-effects. This study is based on a 10 year follow-up of a cardiovascular community intervention programme in northern Sweden. Methods Both quantitative and qualitative approaches were used to address the interaction between changes in self-rated health and risk factor load. Qualitative interviews contributed to an analysis of how the outcome was influenced by health related norms and attitudes. Results Most people maintained a low risk factor load and a positive perception of health. However, more people improved than deteriorated their situation regarding both perceived health and risk factor load. "Ideal types" of attitude sets towards the programme, generated from the interviews, helped to interpret an observed polarisation for men and the lower educated. Conclusion Our observation of a socially and gender differentiated intervention effect suggests a need to test new intervention strategies. Future community interventions may benefit from targeting more directly those who in combination with high risk factor load perceive their health as bad and to make all participants feel seen, confirmed and involved.